Keep Your Loved One Safe in the ICU

Karen A. Friedman, MD, vice chair for education, residency program director and associate professor of medicine in the department of medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Manhasset, New York. Dr. Friedman is coauthor, with Sara L. Merwin, MPH, of The Informed Patient: A Complete Guide to a Hospital Stay.

Published Date: February 1, 2018

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When a loved one or a close friend is in the hospital, it can be unsettling. But when that person is admitted to an intensive care unit (ICU), the stakes are much higher. A patient doesn’t end up in an ICU (sometimes called a “critical-care unit”) unless he/she is very ill and in need of close monitoring and often complex care.

If your loved one is in the ICU, it can be frightening for the patient…and for you. Your loved one is typically hooked up to life-supporting equipment inside a glassed-in room that is devoid of privacy so that nurses can keep a close eye on the patient. Aside from the beeping sounds produced by the medical equipment, the ICU can be eerily quiet—the background hum of TV shows and casual conversation you might hear on a typical hospital floor are absent.

Because the ICU is designated for the sickest patients, you may be tempted to just stand back (or even stay away) and let the professionals do their jobs. But that would be a mistake. Every hospital patient needs an advocate and that’s especially true for people in the ICU—many of whom are heavily sedated and hooked up to breathing machines (ventilators), making it difficult or impossible for them to participate in their own care.

To be sure your loved one gets the best possible care in the ICU, here are the secrets you need to know…

SECRET #1: Don’t assume that the ICU is off-limits to you. Traditionally, ICUs have had stricter visiting rules than other hospital units. Even close family members were urged to visit only briefly and at certain times. But that is changing because many ICU professionals now recognize that loved ones can help patients feel more secure and less anxious…and provide information—for example, background about chronic health problems or prior hospitalization issues such as confusion—that allows the care team to understand patients better.

ICUs with flexible visiting policies are safer and give higher-quality care, according to an analysis of research by the American Association of Critical-Care Nurses. That’s why many ICUs now allow family members and friends to visit any time, 24 hours a day, unless patients object. If your loved one is in an ICU that still has more restrictive policies, speak to the nurse manager and ask whether there can be some flexibility. (You can even show the person this article to help explain your position.)

SECRET #2: Make sure you know which doctor is in charge. You might be surprised to learn that the doctor in charge of your loved one’s care in the ICU may not be one of his regular doctors. Instead, the lead doctor may be an intensivist, a medical doctor who specializes in critical care and is employed by the hospital.

If you are in a specialized ICU—one that focuses on cardiac care, for example—the lead doctor will be a specialist in that field. You should also ask the intensivist to provide regular updates to your loved one’s primary doctor.

You have every right to speak with your loved one’s lead doctor a minimum of once a day. Just ask what the best time is for a debriefing. If you’re not able to coordinate for an in-person conversation, a phone call can be arranged.

SECRET #3: Stay focused on the next steps in your loved one’s care. When you speak with the lead physician for a daily update, listen to what he has to say, but also guide the conversation to the next steps of your loved one’s care.

You might say something like: “Is my loved one moving forward…is he the same…or is he taking steps backward? If he is going backward, why do you think that’s occurring, and what are we doing about it?” You also will want to ask about any new tests being ordered and/or test results and how they may affect your loved one’s care plan. And don’t forget to ask how well your loved one is eating and whether there were any problems overnight.

SECRET #4: Advocate for your loved one to be taken off the breathing machine as soon as possible. Often, someone in the ICU is so sick that he needs to breathe with the help of a machine. But the longer someone uses one of these machines, the more likely the person is to suffer complications, such as pneumonia, or become dependent—that is, less able to breathe on his own.

There should be a step-by-step plan (or “protocol”) for weaning the patient when (and if) he improves. One crucial step involves giving the patient at least one opportunity to take breaths unassisted before the breathing tube is removed. If the breathing tube must be reinserted, it can be traumatic for the patient and is associated with continued risk for lower oxygen levels and low blood pressure.

SECRET #5: Make sure the staff is doing everything possible to prevent delirium. About two-thirds of ICU patients become delirious. This occurs when someone enters the hospital in a normal mental state, then suddenly becomes confused, agitated or quiet and withdrawn. Someone already suffering from dementia can get worse. Elderly people are especially at risk.

Recently, many ICU staffs have developed protocols for preventing or diminishing delirium. For example, the use of sedatives and pain medications (such as benzodiazepines and narcotics) is closely monitored to make sure they are not leading to delirium. In some cases, the drug can be discontinued or the dose can be lowered.

SECRET #6: Beware of physical deconditioning.Regardless of your age or fitness level, spending day after day immobile in bed can take a toll—the average ICU patient loses about 12% of his muscle strength each week.

Regular visits from a physical therapist, who can exercise the body of a patient who is even unconscious, can help. The goal should be to get patients up and moving on their own as soon as possible. In many ICUs, even some patients on ventilators are helped to walk a bit each day.

Important: If you are unable to visit the ICU, call the care team (primary nurse and intensivist) to explain that you are following your loved one’s daily progress and want to be informed of any changes.

A CRUCIAL ICU FACT YOU SHOULD KNOW

On a typical hospital floor, each nurse may care for five or six patients. In most ICUs in the US, each nurse cares for just one or two patients per shift to make sure that each one gets adequate attention.

Because the level of nursing care is directly tied to an ICU patient’s recovery, it’s smart to ask the nurse how many other patients he is caring for (the nurse-to-patient ratio). If the ratio is three or four patients per nurse, seek out the ICU nurse manager and ask what’s going on. It may be that someone called in sick or late, reinforcements are on the way and the manager can take up the slack for a while.

If there’s no good explanation, your loved one may be in danger. Because critical-care patients need frequent adjustments of their ventilators and medications, there may be significant delays if the nurse is busy with other patients. Speak to the physician in charge, and if needed, bump your concerns up to hospital administrators.

Recent development: Some smaller or isolated hospitals deal with staff shortages by relying on skilled doctors and nurses elsewhere to monitor patients by video, at least some of the time. Such “tele­medicine” arrangements can work well if there’s excellent communication and collaboration among all the professionals involved.

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